Oclusión basilar pediátrica tratada mediante trombectomía con stents extractores / A paediatric case of basilar occlusion treated with mechanical thrombectomy using stent retrievers

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Recanalization and mortality rates of thrombectomy with stent-retrievers in octogenarian patients with acute ischemic stroke.

BACKGROUND: Our objective was to evaluate the effect of treatment with stent-retrievers in octogenarians suffering an acute ischemic stroke. METHODS: A total of 150 consecutive patients with acute stroke who were treated with stent-retrievers between April 2010 and June 2012 were retrospectively reviewed. Patients were divided into those <80 years old (n = 116) and those ≥80 (n = 34). Baseline characteristics, procedure data, and endpoints (postprocedural NIHSS, death, and mRS at 3 months) were compared. RESULTS: High blood pressure, atrial fibrillation, and anticoagulation were more frequent in octogenarians (p = 0.01, 0.003, and 0.04 respectively). There were no differences between both groups regarding previous intravenous thrombolysis (32.4 vs. 48.3 %, p = 0.1), preprocedural NIHSS (18.1 vs. 16.8, p = 0.3), procedure time (74.5 (40-114) min vs. 63 (38-92) min, p = 0.2), revascularization time (380.5 (298-526.3) min vs. 350 (296.3-452.8), p = 0.3), TICI ≥ 2B (88.2 vs. 93.9 %, p = 0.1), and symptomatic haemorrhage (5.9 vs. 2.6 %, p = 0.3). Discharge NIHSS was higher in octogenarians (9.7 vs. 6.5, p = 0.03). Death and 3-month mRS ≥3 were more frequent in octogenarians (35.3 vs. 17.2 %, p = 0.02 and 73.5 vs. 37.1 %, p = 0.02). ICA-involvement and prolonged revascularization involved higher mortality (66.7 vs. 27.6 %, p = 0.03) and worse mRS (50 vs. 24.4 %, p = 0.06) in octogenarians. CONCLUSIONS: In our series, treatment with stent-retrievers in octogenarians with acute ischemic stroke achieved good rates of recanalization but with a high mortality rate. ICA involvement and revascularization times beyond 6 hours associated to a worse prognosis. These data might be of value in the design of prospective studies evaluating the clinical efficacy of the endovascular treatments in octogenarians.

Comparison between proximal versus distal protection devices in 287 cases of carotid revascularization using angioplasty and stenting: periprocedure complications, morbidity, and mortality.

BACKGROUND: Embolic protection devices may decrease periprocedural thromboembolic complications during carotid angioplasty and stenting (CAS). When using proximal-protection devices (PPDs), protection starts before crossing the lesion. However, in the medical literature, its use is scarcely reported compared with that of distal-protection filters (DPDs). The objective of this study was to compare periprocedure complications, morbidity, and mortality among 287 consecutive cases of CAS performed with PPDs or DPDs. PATIENTS AND METHODS: This was a retrospective analysis of 287 patients treated with CAS at our hospital between January 2006 and March 2012. Periprocedure complications, morbidity, and mortality at 30 days, including ischemic stroke or transient ischemic attack, reperfusion syndrome, myocardial infarction (MI), and death, were globally registered, and the results in PPD and DPD groups were compared. RESULTS: Two hundred eight patients were treated with DPD and 79 with PPD; 80.8 % were symptomatic. CAS procedures performed with PPD presented a statistically significant greater grade of stenosis than those with DPD (82.5 vs. 74.5 %, p < 0.001). Death rates were 1.9 and 1.3 %; stroke rates were 4.3 and 3.8 %; MI rates were 1.4 and 1.3 %; and total morbidity and mortality rates were 6.2 and 5 % (DPD and PPD groups, respectively); all differences were nonstatistically significant. No statistical difference was found between symptomatic and asymptomatic patients. CONCLUSION: Carotid angioplasty and stenting is a safe procedure to treat carotid disease in our patients. PPDs are not always associated with a greater risk of periprocedure complications, morbidity, and mortality than DPDs despite the greater grade of carotid stenosis in the PPD group. This observation may be of interest in the design of future studies with CAS.

Manifestaciones neurológicas de los mixomas cardiacos. Experiencia en un centro de referencia / Neurological manifestations of cardiac myxoma: Experience in a referral hospital

Introducción: El mixoma cardiaco es una causa poco frecuente pero importante de infarto cerebral en pacientes jóvenes. Existen pocas series de pacientes que analicen la frecuencia de las manifestaciones neurológicas en pacientes con mixoma y su presentación clínica. Objetivo: Conocer las complicaciones neurológicas del mixoma cardiaco en nuestro hospital durante los últimos 28 años. Pacientes y métodos: Revisión retrospectiva de las manifestaciones neurológicas de 36 pacientes operados de mixoma cardiaco con confirmación patológica en nuestro centro desde diciembre de 1983 hasta marzo del 2012. Resultados: Ocho de los 36 pacientes con mixomas cardiacos (22%) intervenidos en nuestro centro presentaron clínica neurológica. El 50% eran mujeres y la edad media ± desviación estándar de 52,4 ± 11,6 años. El síntoma neurológico más frecuente fue la hemiparesia de aparición brusca (63%). El ictus isquémico establecido fue la manifestación clínica más frecuente (75%), seguido del accidente isquémico transitorio. El territorio más afectado fue el de la arteria cerebral media. En todos los casos se alcanzó el diagnóstico del tumor mediante ecocardiografía. El tamaño medio del mixoma fue de 4,12 cm. La mayoría (63%) presentaba una superficie polipoide. Todos los tumores fueron resecados quirúrgicamente con éxito. No hubo muertes hospitalarias. Conclusiones: Los mixomas cardíacos comienzan frecuentemente con manifestaciones neurológicas, en particular como eventos isquémicos (AIT o ictus establecidos) en pacientes jóvenes y sin factores de riesgo cardiovascular. El territorio anterior, en especial la arteria cerebral media, suele estar más frecuentemente afectado. La ecocardiografía puede facilitar el diagnóstico y permitir un tratamiento precoz de la lesión (AU)

Introduction: Cardiac myxoma is an important but uncommon cause of stroke in younger patients. Few published case series analyse the frequency and clinical presentation of neurological complications in patients with myxoma. Objective: To list all neurological complications from cardiac myxoma recorded in our hospital in the past 28 years. Patients and methods: We retrospectively reviewed the neurological manifestations of cardiac myxoma in patients treated in our hospital between December 1983 and March 2012. Results: Of the 36 patients with cardiac myxoma, 8 (22%) presented neurological manifestations. Half were women and mean age of patients was 52.4 ± 11.6 years. Sudden-onset hemiparesis was the most frequent neurological symptom (63%). Established ischaemic stroke was the most common clinical manifestation (75%), followed by transient ischemic attack. The most commonly affected territory corresponded to the middle cerebral artery. Myxoma was diagnosed by echocardiography in all cases. Mean myxoma size was 4.1 cm and most of the tumours (63%) had a polypoid surface. All tumours were successfully removed by surgery. There were no in-hospital deaths. Conclusions: Cardiac myxomas frequently present with neurological symptoms, especially ischaemic events (established stroke or transient ischaemic attack), in younger patients with no cardiovascular risk factors. The anterior circulation is more frequently affected, especially the middle cerebral artery. Echocardiography can facilitate prompt diagnosis and early treatment of the lesion (AU)

Neurological manifestations of cardiac myxoma: experience in a referral hospital.

INTRODUCTION: Cardiac myxoma is an important but uncommon cause of stroke in younger patients. Few published case series analyse the frequency and clinical presentation of neurological complications in patients with myxoma. OBJECTIVE: To list all neurological complications from cardiac myxoma recorded in our hospital in the past 28 years. PATIENTS AND METHODS: We retrospectively reviewed the neurological manifestations of cardiac myxoma in patients treated in our hospital between December 1983 and March 2012. RESULTS: Of the 36 patients with cardiac myxoma, 8 (22%) presented neurological manifestations. Half were women and mean age of patients was 52.4 ± 11.6 years. Sudden-onset hemiparesis was the most frequent neurological symptom (63%). Established ischaemic stroke was the most common clinical manifestation (75%), followed by transient ischemic attack. The most commonly affected territory corresponded to the middle cerebral artery. Myxoma was diagnosed by echocardiography in all cases. Mean myxoma size was 4.1cm and most of the tumours (63%) had a polypoid surface. All tumours were successfully removed by surgery. There were no in-hospital deaths. CONCLUSIONS: Cardiac myxomas frequently present with neurological symptoms, especially ischaemic events (established stroke or transient ischaemic attack), in younger patients with no cardiovascular risk factors. The anterior circulation is more frequently affected, especially the middle cerebral artery. Echocardiography can facilitate prompt diagnosis and early treatment of the lesion.

Treatment of acute vertebrobasilar occlusion using thrombectomy with stent retrievers: initial experience with 18 patients.

BACKGROUND AND PURPOSE: Acute vertebrobasilar occlusion is an ominous disease with few proved effective treatments. Experience with stent retrievers is scarce and limited to combined therapies (stent retrievers associated with previous intravenous fibrinolysis, intra-arterial thrombolysis, or other mechanical devices). We present our experience with 18 patients treated with direct thrombectomy by using stent retrievers. MATERIALS AND METHODS: Eighteen patients with vertebrobasilar occlusion were treated with direct thrombectomy by using stent retrievers at our hospital. The mean age was 67.5 years. Clinical presentation was sudden deterioration in consciousness level in 61.2% and progressive or fluctuating brain stem symptoms in 38.8%. Stroke subtype (TOAST) was atherothrombotic (33.3%), undetermined (33.3%), cardioembolic (27.7%), and of unusual etiology (5.5%). RESULTS: The occlusion site was the vertebral artery in 1 case, proximal basilar artery in 4, middle basilar artery in 6, distal basilar artery in 5, and unilateral posterior cerebral artery in 2 cases. SRs included the Solitaire AB in 8 cases, Solitaire FR in 5 cases, and Trevo Pro in 5 cases. An 8F Merci balloon guide catheter was used in 15 patients, and a Neuron 6F, in 3 patients. Post-clot retrieval definitive intracranial stents were used in 5 patients (27.7%). Postprocedural TICI ≥ 2b was achieved in 17 patients (94.4%). Clinically, 72.2% of patients experienced an improved NIHSS score at discharge, 22.2% died, and in 5.5% the NIHSS scores did not change. The mRS score at 3 months was 0-2 in 9 patients (50%) and 3-5 in 5 patients (27.7%). CONCLUSIONS: Thrombectomy with stent retrievers is feasible in the treatment of vertebrobasilar occlusion. These initial results must be confirmed by further prospective studies with a larger number of cases.

Hemorrhage/contrast staining areas after mechanical intra-arterial thrombectomy in acute ischemic stroke: imaging findings and clinical significance.

BACKGROUND AND PURPOSE: The aim of this study was to report the CT evolution and clinical significance of HCA after intra-arterial mechanical thrombectomy (revascularization by using retrievers and/or other mechanical devices without concomitant delivery of intra-arterial thrombolytics) in our patients. These lesions are common after intra-arterial thrombolysis, being considered a negative prognostic sign. Their significance after pure mechanical thrombectomy remains unknown. MATERIALS AND METHODS: Forty-eight patients were treated with mechanical thrombectomy by using retrievable stents between April 2010 and February 2011. All patients underwent initial (first 24 hours) and follow-up (48-72 hours) nonenhanced CT. We retrospectively analyzed the clinical and radiologic data of the patients with HCA and compared them with controls. RESULTS: Fifteen of 48 patients presented with HCA. The site of occlusion was the MCA in 7 patients, both the extra- and intracranial segments of the ICA in 6, and the intracranial ICA in 2. In 7 patients, previous intravenous thrombolysis was administered. Complete recanalization (TICI 3) was achieved in 12 patients, and incomplete recanalization (TICI 2b), in 3. The location of HCA was the subarachnoid space in 6 patients, the brain parenchyma in 4 patients, and both in 5 patients. The HCA were asymptomatic in all patients. There was no statistical difference in final NIHSS score reduction (NIHSS pretreatment-NIHSS at discharge) between patients and controls. CONCLUSIONS: In our series, HCA are common after mechanical thrombectomy but do not carry an increased risk of symptomatic hemorrhage or negative prognosis. These data might be related to the high rate of recanalization and the absence of intra-arterial thrombolytics.

TGGE analysis of the diversity of ammonia-oxidizing and denitrifying bacteria in submerged filter biofilms for the treatment of urban wastewater.

The spatial and temporal diversity of the bacterial community-forming biofilms in a pilot-scale submerged biofilter used for the treatment of urban wastewater was analyzed by a temperature-gradient gel electrophoresis (TGGE) approach. TGGE profiles based on partial sequence of the 16S rRNA gene showed that the community composition of the biofilms remained fairly stable along the column system and during the whole time of operation of the biofilter (more than 1 year). Community-profiling based on the amplification and separation of partial ammonia monooxygenase (amoA) and nitrous oxide reductase (nosZ) genes demonstrated that ammonia-oxidizing and denitrifying bacteria coexisted in both the anoxic and the aerated parts of the system. Several amoA and nosZ bands separated by TGGE were reamplified and sequenced, in order to further analyze the composition of these microbial communities in the biofilm. Phylogeny inferred from amoA/AmoA revealed the prevalence of Nitrosomonas species with five sequences affiliated to Nitrosomonas oligotropha, six sequences affiliated to Nitrosomonas europaea, and three sequences that showed only 75.7-76.1% identity of the DNA sequence with the closest described species (Nitrosomonas nitrosa). According to literature, this low identity value is indicative of previously undiscovered species. Eighteen new partial nosZ sequences were obtained which were mostly related to nosZ of gamma-proteobacteria (Pseudomonas) or clustered in the periphery of previously known denitrifying alpha-proteobacteria (Bradyrhizobium and Azospirillum).

Analysis of community composition of biofilms in a submerged filter system for the removal of ammonia and phenol from industrial wastewater.

The bacterial diversity of a submerged filter, used for the removal of ammonia and phenol from an industrial wastewater with high salinity, was studied by a cultivation-independent approach based on PCR/TGGE (temperature-gradient gel electrophoresis). The wastewater treatment plant (laboratory scale) combined the nitrification and denitrification processes and consisted of two separated columns (one anoxic and one aerated) connected through a valve. The spatial diversity of bacterial communities in the plant biofilms was analysed by taking samples at four different heights in the system. TGGE profiles of PCR-amplified sequences of the 16 S rRNA gene (V3-hypervariable region) showed significant variations of the bacterial diversity, mainly depending on the concentration of O(2) along the system. Several bands separated by TGGE were reamplified and sequenced, in order to explore the composition of the microbial communities in the biofilms. Most of the sequenced bands (10 out of 13) were closely related to the 16 S rRNA gene of marine alpha-proteobacteria, mainly grouping in the periphery of the genus Roseobacter. Other sequences were related to those of gamma-proteobacteria, the nitrite oxidizer Nitrospira marina and anaerobic phenol-degrading bacteria of the Desulfobacteraceae.

[Face recognition in autism]. / Reconocimiento de caras en autismo.

INTRODUCTION: We conducted a survey of the literature on face recognition (FR), an activity that is essential for social relations and their dynamics. Unlike the recognition of non facial objects, this type of recognition is a special process since it is based on the detection of individual features. The most characteristic clinical parameter of autistic subjects is their inability to relate socially, possibly due to the difficulty they have in processing faces, although they are more skilled at recognising objects. DEVELOPMENT: We describe the two mechanisms involved in FR, one based on features and the other referring to the whole. The latter can be further divided into overall processing that allows a whole image to be compared with another previously assimilated image, and the processing of the arrangement of a face that is recognised as a whole. These may correspond to two different neuronal pathways. During the first days of life, the newborn baby has a predilection for faces in their feature and overall aspects, and processing of the arrangement is slower. Visual development in autistic children is erratic, similar to the level of a newborn infant, and their lack of interest for human faces is apparent during the first year of life, as they look at everything as if they were objects, that is, by features. CONCLUSIONS: The analysis of the literature enabled us to determine how FR mechanisms develop in the earliest days of the infant s life. It also highlighted the importance of the integrity of the pathway that facilitates stimulation for the recognition of facial arrangement, which is altered in autistic children perhaps from the peripheral area to the cortex. Further work on peripheral pathways and the fundamental cortical connections that are affected in autistic subjects will help us to understand the inefficiency of their facial arrangement recognition system.

Reconocimiento de caras en el autismo / Face recognition in autism

Introducción. Se realiza una revisión bibliográfica sobre el reconocimiento de caras (RDC), actividad fundamental para las relaciones sociales y su dinámica. Este tipo de reconocimiento es un proceso especial, en contraste con el reconocimiento de objetos no faciales, pues se basa en la detección de características individuales. El parámetro clínico más característico de los autistas es su imposibilidad para la relación social, posiblemente por su dificultad para el procesamiento de caras, aunque poseen una mayor habilidad en el reconocimiento de objetos. Desarrollo. Se plantean los dos mecanismos en el RDC, el de los rasgos y el de conjunto. El segundo comprende el procesamiento global, que permite comparar la totalidad de la imagen con una imagen previamente asimilada, y el procesamiento de la configuración de la cara reconocida como un todo; ambos pueden corresponder a dos redes neuronales distintas. En los primeros días de vida, el recién nacido tiene preferencia por las caras en sus aspectos de rasgos y global, y es más lento el proceso de la configuración. El desarrollo visual en los niños autistas es errático, como si fuese el nivel de un recién nacido, y su desinterés por las caras humanas es evidente en el primer año de vida, al mirar todo como objetos, por rasgos. Conclusiones. El análisis de la bibliografía ha permitido plantear cómo se desarrollan los mecanismos de lRDC desde los primeros días de vida, y la importancia que desempeña la integridad de la vía que facilita la estimulación para el reconocimiento de la configuración facial, alterada en los niños autistas, posiblemente desde la periferia al córtex. Nuevos trabajos sobre las vías periféricas y las conexiones corticales fundamentales afectadas en autistas ayudarán a comprender la ineficiencia de su sistema de reconocimiento de la configuración facial (AU)

[Cognitive evoked potentials in autistic children]. / Potenciales evocados cognitivos en niños autistas.

AIMS: The aim of this study was to examine the latency, amplitude and distribution of N400 potential in order to evaluate the semantic processing capacity in autistic children and in children suffering from Asperger s syndrome (AS), and to compare them with a control group. PATIENTS AND METHODS: 24 autistic children, six boys with AS and 25 controls, aged between 6 and 14 years old. The cases were examined using the DSM IV diagnostic criteria. Auditory stimulation was performed with pairs of congruent and incongruent words: two lists of 20 pairs of semantically related words (congruent) and 20 pairs of words with no semantic relationship whatsoever (incongruent). RESULTS: The most striking parameter is the increase in latency in N400 for the group of autistic children, which did not occur in the group of children with AS. Maximum N400 negativity for the children with autism was found in the left frontocentral region. No significant differences were observed for the amplitude of N400 between the three groups that were studied. CONCLUSION: Neurophysiologically, the autistic children and those affected by AS perhaps use different neuronal networks in semantic processing. The N400 wave can be a valid test for monitoring verbal processing in these children.

Potenciales evocados cognitivos en niños autistas / Cognitive evoked potentials in autistic children

Objetivo. Estudiar la latencia, amplitud y distribución del potencial N400 para valorar la capacidad de procesamiento semántico en niños autistas y en niños con síndrome de Asperger (SA) y compararlos con un grupo control. Pacientes y métodos. 24 niños autistas, seis niños con SA y 25 controles, con edades comprendidas entre 6 y 14 años. Se utilizaron los criterios diagnósticos del DSM-IV para los casos. Se realizó una estimulación auditiva con pares de palabras congruentes e incongruentes: dos listas de 20 pares de palabras relacionadas semánticamente (congruentes) y 20 pares de palabras sin relación semántica alguna (incongruentes). Resultados. El parámetro más llamativo es el incremento de la latencia en la N400 para el grupo de autistas, que no fue así en el grupo de niños con SA. La máxima negatividad de la N400 para los niños con autismo se localiza en la región frontocentral izquierda. No se observaron diferencias significativas para la amplitud de la N400 entre los tres grupos estudiados. Conclusión. Neurofisiológicamente, los niños autistas y los afectos de SA posiblemente utilizan redes neuronales diferentes para el procesamiento semántico. La onda N400 puede ser un test válido para el seguimiento del procesamiento verbal de estos niños (AU)

Aims. The aim of this study was to examine the latency, amplitude and distribution of N400 potential in order to evaluate the semantic processing capacity in autistic children and in children suffering from Asperger’s syndrome (AS), and to compare them with a control group. Patients and methods. 24 autistic children, six boys with AS and 25 controls, aged between 6 and 14 years old. The cases were examined using the DSM IV diagnostic criteria. Auditory stimulation was performed with pairs of congruent and incongruent words: two lists of 20 pairs of semantically related words (congruent) and 20 pairs of words with no semantic relationship whatsoever (incongruent). Results. The most striking parameter is the increase in latency in N400 for the group of autistic children, which did not occur in the group of children with AS. Maximum N400 negativity for the children with autism was found in the left frontocentral region. No significant differences were observed for the amplitude of N400 between the three groups that were studied. Conclusion. Neurophysiologically, the autistic children and those affected by AS perhaps use different neuronal networks in semantic processing. The N400 wave can be a valid test for monitoring verbal processing in these children (AU)

[Nocturnal polysomnogram in childhood autism without epilepsy]. / Polisomnograma nocturno en el autismo infantil sin epilepsia.

AIMS: To evaluate the presence of epileptiform discharges and the organisation of nocturnal sleep of autistic children without nocturnal polysomnographic epileptic seizures. SUBJECTS AND METHODS: Cross section analysis. SUBJECTS: 21 boys and girls with autistic spectrum using DSM IV criteria between the ages of 4 and 12, compared with a control group made up of normal children of the same ages. METHODS: nocturnal polysomnogram with a minimum efficiency of 75%. ANALYSIS: t test to compare the cycles and phases of sleep with significance p< 0.05. RESULTS: SUBJECTS presented a maximum of four sleep cycles compared with five or six in the control subjects. From the first third of the night onwards there was an increase in the slowest phases. 66% presented epileptiform paroxysmal discharges, all of which originated in the anterior half of the brain. CONCLUSION: Sleep is not destructured, but it is reduced in length, with epileptiform paroxysms of predominantly frontal origin. This could indicate that these two parameters are intrinsic to the autistic spectrum, as well as indicating a more focused origin of the generalised picture which is possibly closely related with the qualitative alteration of the social experiences of these children.

Polisomnograma nocturno en el autismo infantil sin epilepsia / Nocturnal polysomnogram in childhood autism without epilepsy

Objetivo. Valorar la presencia de descargas epileptiformes y la organización del sueño nocturno en niños autistas sin crisis epilépticas polisomnográficas nocturnas. Sujetos y métodos. Diseño analítico de sección transversal. Sujetos: 21 niños y niñas con espectro autista según DSM-IV entre 4 y 12 años de edad, compa ados con un grupo control de niños normales de las mismas edades. Métodos: polisomnograma nocturno con eficiencia mínima del 75 por ciento. Análisis: test t para comparar los ciclos y fases del sueño con significación p< 0,05. Resultados. Los sujetos presentaron un máximo de cuatro ciclos de sueño frente a cinco o seis de los controles. Se produjo un incremento de las fases más lentas a partir del primer tercio de la noche. Un 66 por ciento presentó descargas paroxísticas epileptiformes, todas con origen en la mitad anterior del cerebro. Conclusión. No existe desestructuración del sueño, pero sí reducción de su duración, con paroxismos epileptiformes de origen predominantemente frontal, lo que puede indicar que estos dos parámetros son intrínsecos al espectro autista, además de señalar un origen más focal del cuadro generalizado, y posiblemente muy relacionados con la alteración cualitativa de las vivencias sociales de esos niños (AU)

Mortalidad neonatal en el Paraguay: análisis de los indicadores / Neonatal mortality in Paraguay: analysis of the indicators

La experiencia obtenida en varios países sugiere que podría reducirse la mortalidad neonatal (MN) aplicando ciertas medidas simples y lógicas. Objetivos: Describir las características de las muertes neonatales ocurridas en los años 1995-1996-1997-1998 y analizar los factores que podían tener gran impacto en la disminución de la MN en el Paraguay. Material y método: Revisión y análisis retrospectivos de los riegistro del departamento de bioestadística dependiente de la unidad de planificación del Ministerio de Salud Pública y Bienestar Social en los documentos denominados indicadores de mortalidad, año 1995-1998, la fuente de información básica de los documentos lo constituye el certificado de defunción de cada recién nacido (RN). Resultados: de 1995 a 1998 se registraron 343.047 nacidos vivos, la mortalidad neonatal correspondió a un 52,9 porcientos (n=3.638) del total de la mortalidad infantil. Del total de fallecidos 8 porcientos fueron menores de 1000 gr, 12 porcientos de 1000 a 1499, 11 porcientos de 1500 a 1999, 11 porcientos de 2000 a 2499 y el 38.5 porcientos mayor o igual a 2500. El 78 porcientos de los RN falleció antes de los 7 días de vida. La cuasa principal de muerte la constituyo lesiones debidas a parto (35 porcientos) seguida de infecciones (19 porcientos) prematuridad (17,5 porcientos) y malformaciones congénitas (12 porcientos). Las regiones sanitarias con tasa de mortalidad neonatal más alta fueron Misiones (17x1000), Guairá (16,2x1000), Candindeyu (14,3x1000), Alto Paraná (13,4x1000), Ñeembucu (13,4x1000), Asunción (11x1000). El 77 porcientos de todos los RN fallecidos recibieron asistencia médica. El 73 porcientos de las muertes de RN en los registros de 1995-1998 en Paraguay son por causas altamente evitables y un número importante de RN con pesos de nacimiento normales son afectados. La causa principal esta asociada a hipoxia perinatal y si bien la mayor parte es asistido por un profesional médico, el nacimiento estimado de 164.000 niños al año, obliga a buscar estrategias que mejoren la calidad de atención de los RN sin la necesidad de equipos muy sofisticados